September 30, 2010

The Power of Praise ... Use it Wisely

by Brian L’Heureux, Pharm.D., PGY1 Pharmacy Practice Resident, Suburban Hospital

I’m sure you’ve been in the same situation.  The big presentation is finally over, and now it’s time for the evaluation.  Hoping for some valuable feedback to further improve your presentation content or hone your presentation skills, all you get is a “good job, great presentation or maybe a “keep up the good work.”

In today’s culture, feedback always seems to come heavy on the praise and light on the criticism, for fear of hurting the
student’s self-esteem.  While no student or teacher would enjoy outright criticism, praise can be equally damaging by not affording students opportunity to better themselves intellectually. In trying not to trample on a person’s self-esteem, feedback is falling flat and teachers are often not giving enough content to enable students to better their skills.  Is the problem the lack of constructive criticism?  Or is it the type or the amount of praise given?

In “How Not to Talk to Your Kids,” an article that appeared in the New York Magazine, Po Bronson writes about the inverse power of praise, and how too much praise may actually hinder intellectual growth.  Although the research presented was primarily done in elementary school-aged children, there is a definite connection with learners of any age.  The article outlines what characteristics of praise produce negative outcomes and the kind of praise that promotes the best results.  Praise should emphasize the student’s effort, be specific by highlighting the behaviors that are desirable, and be genuine.  Research by Dr. Carol Dweck indicates that when students were continuously praised on their intelligence, which is a quality that is outside of students’ control, they are more likely to underestimate their skills and only attempt easy tasks for fear of showing their intellectual vulnerabilities.  Dweck also demonstrated that when students are praised on their effort, which is something they can control, the children were more likely to try harder tasks and therefore have the opportunity to learn and improve their skills.  Secondly, praising specific behaviors, not issuing general platitudes, has been shown in many studies to be most effective.  One study described the effects of selective and specific praise on a losing hockey team.  The team started winning when they were given self-esteem boosting praise that was specifically directed at the number of checks each player gave during games.  Lastly, the article points out that by the age of 7, children become suspicious of praise.  If the child determines that the praise is disingenuous, the student may feel patronized and that the praise signifies that they’ve reached the limit of their capabilities.  Constructive criticism on the other hand, can signify to a student that they still have the ability to improve their skills.

To bring into the context of the issues we are discussing in this course, the “praise” described in the article is feedback, and the students are adults.  As pharmacists, we can appreciate the fact that learning continues throughout our lives.  Thinking back on the feedback that I’ve received in the past, I’m starting to see how I was impacted – positively and negatively.  The author also alludes to the fact that great feedback requires a good deal of effort.  The next time that you have the opportunity and responsibility of providing feedback to someone, consider the potential impact you can have on their development.  The effort can certainly be worth it.

Bronson, P.  “How Not to Talk to Your Kids.”  New York Magaine. 2007: Feb 19.

[Editor's Commentary:  Feedback is a critical component of the learning process.  Feedback from teachers can be especially powerful.  Feedback not only helps students focus on the things they did well and points out the things they can (should) improve ... but it also impacts students' motivation to learn.  Most of us think of feedback as a dichotomy - its either praise (uplifting, positive speak) or criticism (disheartening, negative speak).  Praise is believed to affirm a person's self-esteem.  While criticism is generally believed to be (potentially) destructive or harmful.  While there is little doubt that criticism can be a used (intentionally or unintentionally) like a weapon to breakdown and diminish people, praise can have a corrosive effect too.  In the book "Punished by Rewards," Alfie Kohn describes how the use of carrots (and sticks) has inadvertent and negative consequences in our schools, the workplace, and at home.  The judicious use of "praise" in the form of describing specific behaviors that the teacher feels is desirable can help students (children or adults) know what they are doing well.  But growth can only come when the teacher is willing to point out what could be done better.  Striving for better does not imply that the performance was "bad" or "poor."  It simply means there is room for growth.  And frankly, isn't there ALWAYS room for growth?  Constructive criticism, delivered in a manner that suits the individual's learning style and judiciously applied at the right time, is perhaps a teacher's most powerful tool.  Dr. Dweck's research demonstrates that our job is to help student develop a positive (growth) mindset toward learning ... and this can't be accomplished through the indiscriminate use of praise.  -S.H.]

September 24, 2010

E-Learning and Health Professional Education

by Nicholas Fusco, Pharm.D., PGY1 Pharmacy Practice Resident, University of Maryland Medical Center
“Everyone take your seats. Let’s get started. We have a lot to cover today.”
As the lecturer quickly goes through their outline and objectives for the class, you frantically try to organize your mind for the impending deluge of information. Physiology, biochemistry, pathology, pharmacology, clinical guidelines, monitoring parameters, adverse effects and the list goes on. The lecturer unflaggingly presses forward as your wrist begins to cramp from scribbling down each bit of seemingly invaluable information. Soon, you realize you may have missed something and turn to your neighbor for help. You look to the left and find your best friend in Stage 1 of non-REM sleep. You turn to your right and find another classmate starring helplessly at the board, jaw slightly dropped, eyes glazed and you wonder if you should check his vital signs. While all this has transpired, the lecturer has moved on. No time for stragglers. Every student for themselves! Before you know it, the lecture is over. You’re left floating in a sea of new information. I hope you can swim (or at least brought a raft).
Sound familiar? Traditional, instructor-centered teaching placed the teacher in control of the learning experience. Increasing demands on academic faculty to accommodate the ever-expanding field of biomedical science and to incorporate new fields of practice has challenged the way in which they deliver this information. Emerging from these challenges is a new, learner-centered model that allows the student to be in control of their learning experience. One vehicle by which information can be delivered that supports the learner-centered model is that of “E-learning” or Web-based learning. E-learning is the use of any Internet or computer-based technology as a source of instruction. It can be broken in to two broad categories of distance learning and computer-assisted instruction. Distance learning describes those technologies that allow for the delivery of information to remote sites from a central location. Computer-assisted instruction utilizes one or more sources of multimedia to aid in the delivery of information. These terms are not mutually exclusive, nor do they need to be separated from traditional, instructor-led learning. In fact, most instructors already take a blended approach, supplementing a traditional lecture with online or computer-based aids.

The advantages of E-learning can be summarized in two main categories, learning delivery and learning enhancement. For the student, well-designed E-learning scenarios increase their accessibility to the content, allows them to customize their learning experience and control the pace, time and even the media by which the instruction is delivered. For the instructor, the ease by which online multimedia can be updated, distributed and standardized sets it apart from traditional print media. Learning enhancement is less well described, but is just as important as learning delivery. As more institutions embrace competency-based curricula, a greater emphasis is being placed on learning outcomes. By allowing the student greater accessibility and customization of online multimedia, E-learning supports a more efficient learning process. Based on it’s interactive nature and the degree of control that the student exhibits over the delivery of the content, E-learning can potentially motivate the student to become more engaged with the content and through this increase retention rates.

A unique challenge of E-learning is in its evaluation. As more learning becomes student-based, the instructor’s role will evolve from a transmitter of information to a facilitator / evaluator of learning. The process of E-learning must be closely evaluated to determine whether the experience was appropriate, well designed, and met the needs of the students that it was intended for. Likewise, outcomes must be measured to determine how efficiently E-learning was able to alter a student’s knowledge or skills. It is important to make a distinction at this point between learner satisfaction and efficacy. E-learning should be interacting and engaging, which certainly will provide some degree of entertainment to the learner. Subjective evaluations of E-learning may yield high levels of learner satisfaction if the experience was fun or entertaining, and may falsely lead the instructor to believe the learning experience was efficient or effective. Poor content can be masked by an entertaining design and may lead to ineffective learning. It is therefore important to develop effective, instructor-mediated strategies for the evaluation of outcomes of E-learning. In many health care professions, the preferred technique for evaluation of skills is direct observation. This can be time consuming, costly and inefficient. A combination of web-based competency evaluations combined with direct observation may allow the instructors to perform a more thorough evaluation of the student’s knowledge, while still engaging the student in traditional, face-to-face assessments. Further development of this area is needed and may potentially be a source of scholarship to academic faculty in the future.

E-learning offers several advantages to both the student and the instructor. Wouldn’t it have been nice to be able to press “Pause” during some lectures to recollect your thoughts before moving on to the next, big idea? Customization of learning experiences may better accommodate different learning styles, which can simultaneously enhance the learning process and improve outcomes. As E-learning becomes a more integral part of health professional education, students and instructors will benefit from this vehicle to navigate the great sea of knowledge.

Ruiz JG, Mintzer MJ, Leipzig RM. The impact of E-learning in medical education. Acad Med 2006;81:207-12.
Leung WC. Competency based medical training: review. BMJ 2002;325:693-6.
Ward JP, Gordon J, Field MJ, Lehmann HP. Communication and information technology in medical education. Lancet 2001;357:792-6.

[Editor's Commentary:  E-learning includes a range of electronic tools (hardware and software) that are employed in the learning process. When most people think about e-learning, they immediately think of computers connected to the Internet but it also includes mobile devices like cell phones and MP3 players … as well as a range of software tools, increasingly web-based applications.  Mobile computing devices and the Internet have revolutionized the way we can deliver instructional materials.  But is this new delivery method better or worse than older methods of deliver (namely, oral expository in a classroom and written materials in the form of books, journals, and handouts)?  This dichotomous question, is e-learning better or worse than traditional methods of learning, forces us to think in terms of either/or rather than examining things in a more holistic manner.  Most instruction delivered through an e-learning conduit is no better or worse than the face-to-face methods it is attempting to “replace.”  Indeed, most instruction delivered online is merely a replica of what would have been delivered had the learner been seated a few feet in front of the teacher. Perhaps the biggest advantage of e-learning is that it often can increase availability and access.  Most e-learning materials are available to students in an enduring way – and accessible from any computer 24/7 anywhere in the world.  Face-to-face instruction often enjoys an advantage with regard to greater social connection and interactivity – thus the transactional distance between the teacher and learners (and among learners) is smaller.  Clearly an important benefit.  Thus institutions and instructors who have embraced “blended learning” have an opportunity to maximize student learning by using a variety of instructional tools and methods, online and in the classroom, exploiting the advantages that each has to offer.  So the decision to use e-learning should not be a yes or no proposition, but rather a who, what, why, when, and how analysis. –SH]

September 14, 2010

Early Practice Experiences & Curricular Reform

by Liana Mark, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

Standard number 11 of the 2006 ACPE Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree states that “the pharmacy school must use and integrate teaching and learning methods that produce graduates who become competent pharmacists by fostering the development and maturation of critical thinking and problem skills.”  The Standards also go on to say that “the pharmacy school must enable students to transition from dependent to active, self-directed lifelong learners.”  This lofty goal is easier said than done, and I am not entirely convinced that the majority of pharmacy school curriculums enable students to achieve these objectives upon graduation.

My school of pharmacy implemented early (i.e. pre-P4) experiential learning into its curriculum after the 2006 Standards were published.  As such, I participated in both introductory and intermediate pharmacy practice experiences during the summers after my P1 and P2 years in addition to P4 advanced pharmacy practice rotations (APPEs).  During the school year, most learning was passive via didactic lectures and, in some cases, active through laboratory experiences and discussions.  Looking back, it seems as though I grew as a professional and as a learner at an exponential rate during my P4 APPEs, compared to the rather modest growth in the first few years of professional schooling.  My capacity to learn and apply resembles a J-curve, with a significant upswing towards the end of my student years.  However, now that I have the ability to look at pharmacy education from a bird’s eye view, I must say that I would have preferred my learning curve to resemble first-order kinetics during those years; with a steady, progressive increase that would have allowed me to build upon my prior knowledge and learn how to problem solve and critically think through problems early on, rather than just retaining factual knowledge and finally having a number of “a-ha!” moments at the end of my student career when everything suddenly fell into place.

So, the question is, how can first-order learning be promoted?  First, we must identify the barriers.  Passive learning techniques employed in the didactic portion of the Pharm.D. program provide limited opportunity for the development of problem solving and critical thinking skills.  This obstacle is mainly due to the factual nature and the sheer volume of information that pharmacy students must learn in order to create a substantial knowledge base.  A student can manage to pass via “cramming” and regurgitating the information on an exam, but this method of retention (because it is clearly not learning) benefits neither the learner nor his/her future patients.  Additionally, factual information, especially in the field of pharmacy, changes from year to year.  Taking this into account, treatment guidelines learned in the P1 year may not be applicable by the time the student reaches APPE rotations.  Thus, honing the skills of critical thinking and problem solving is absolutely necessary to prepare the student pharmacist for independent practice and satisfactory patient care.

Active learning is a more effective learning method for long term retention.  This method of learning includes discussion, practicing by doing, and teaching others.  Experiential learning is employed in many healthcare professions to prepare the student for independent practice, pharmacy included.  However, pharmacy experiential learning comes much later in the student pharmacist education as compared to other healthcare professions, and the experiential learning we do get early on is sparse and, in my experience, not fully maximized.  Students of dentistry, optometry, medicine, and physical therapy all have active, hands-on learning placed very early on in their curricula.  As such, by the time these students graduate, they have a strong fundamental, and, more importantly, applicable, knowledge base.  Individuals in these professions are well-equipped upon graduation to walk into a real-life setting, given that they have been in the setting as an apprentice for years.

A potential solution for student pharmacists is to incorporate weekly practice experience starting in the first few days of the Pharm.D. curriculum.  This integration would allow the student to apply facts learned in the classroom to a real situation, thus enabling him or her to critically think, problem solve, and retain the information in a different way than strictly classroom-based learning allows.  Weekly practice experiences may not be feasible due to course load.  Thus, another solution, which is employed at a number of pharmacy schools, is co-operative experiential learning, wherein the student pharmacist alternates classroom learning and experiential training from one semester to the next.  The experiential training, of course, must be coordinated with the classroom learning of the student.  My school’s current format that consists of IPPEs and APPEs could be maximized by ensuring that preceptors have a better understanding about their responsibility to the pharmacy student and to their profession.

It is clear that pharmacy education lags behind other professions in its active learning experiences.  Pharmacists need to be exposed to real-life situations earlier in their careers in order to meet the ACPE Standard that encourages the development of critical thinking and problem solving capabilities in the Pharm.D. curriculum.  Through active learning techniques, student pharmacists will be able to retain knowledge and create for themselves usable, applicable databases that will serve to improve their clinical abilities as practitioners and, additionally, encourage the pursuit of lifelong learning.

DiPiro JT. Making the most of pharmacy school. Am J Pharm Educ 2008; 72(1) Article 15.
DiPiro JT. Why do we still lecture?  Am J Pharm Educ 2009; 73(8) Article 137. 
[Editor's Commentary:  Is the typical pharmacy curriculum backward ... based on outdated, unproven notions about how people learn?  Should we provide students with experiences first and then talk about the theory and science that supports the practice of pharmacy afterward?  There are perhaps practical reasons why pharmacy schools (and most other professional schools) have elected to front load their curricula with didactic course work and save the practical experiences for the end. But most of the reasons have more to do with scheduling and resource allocation, not pedagogy or instructional design. Let's examine how one would go about teaching people to play a guitar (and to be good enough to make money playing it).  Now, learning how to play a guitar is complicated stuff.  To get really good at it you have to learn new terminology (e.g. adagio, allegro, forte), read (and perhaps even write) an entirely new form of communication (e.g. music notations), play different styles of music, and coordinate your actions with other people who are simultaneously playing their musical instruments or singing. If we approached learning how to play a guitar the same way we approach pharmacy education, we'd have the students sit through a series of didactic lectures about the guitar and its history, about guitar playing techniques, how to select a guitar, how to read music, and how to be a member of a band.  We'd probably have students watch an instructor (or better yet, a resident!) play a guitar in front of the class.  And then we'd have everyone watch videos of Eric Clapton and John Scofield playing guitars - and then debrief about it for 30 minutes.  In addition, we'd have the students participate in 3 or 4 "guitar labs" each semester where three or four students would use the school-provided XBox or PS3 and play "Guitar Hero" (or something like that) - and watch each other play - for a couple of hours.  And then, we'd have a one week observation (P1) and a one-month (P2 and P3) "guitar playing" rotation with a preceptor.  The student probably wouldn't be assigned his or her own guitar to play - but would rather "assist" the preceptor with some guitar playing activities (like, for example, handing the preceptor the right pick to use).  In the fourth year of our "guitar school,"  each of the students would be sent off into the field and would be asked to start playing guitars - 40 hours a week!  This would probably overwhelm our students, who haven't yet built the skills to play guitar very well on their own nor the stamina.  But, during the last year of the curriculum, most of our students would, indeed, get pretty good at it.  Most would become competent guitar players (good enough to be street musicians) and a few would become stars (acclaimed by their audience and peers as truly great musicians).  Many of our students would arrive at our fictitious guitar school with some guitar playing experience - and nearly all of them would be innately interested in guitar playing.  But we wouldn't let them touch a guitar until they've completed a least 16 credit hours of instruction about the latest statistics regarding guitar playing in the US, music theory, and (of course) the physics of sound.
Seems a bit absurd, doesn't it?  If you wanted to learn how to play guitar, the first thing you'd do is pick a guitar and try to make some sounds with it (not take a series of didactic lectures about it).  And a good teacher would encourage you to do so.  In fact, you probably wouldn't be allowed into "guitar school" unless you had access to a guitar and could get practice using it several hours a week.
I encourage you to read a provocative article by Wendy Duncan-Hewitt and Zubin Austin published in AJPE.  I think the traditional pharmacy curriculum is a relic of the past.  Its time to rethink and radically restructure things. -SH]